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Wednesday, December 31, 2014

This article first appeared in the December 2014 issue of the RACGP Publication Good Practice. I have linked to PubMed for the articles, and included links to full text in the references at the end.

One of the most difficult questions in healthcare may be, “Are you a good doctor?”

I am sure,
dear reader, that you are a good doctor. You know everything, and you know the
things you need to learn. You can see through the twinkle in a drug rep’s eye
faster than you can say Vioxx. You are all much better than average, and, even
as you know enough statistics to be able to dismiss this as an impossibility,
you also know that it is certainly not you who is below average.

Now that we
are patting each other on the back in mutual admiration, here are some people
to spoil the party. Let me introduce you to Dr Dunning and Dr Kruger, who won an Ig Nobel prize in 2000 for their work, in experiments showing those who were the least competent in various tasks were also the most likely
to rate themselves highly competent.

They also found the same people are the most self-confident. There’s
something about not being very good at something that makes you blind to the
areas that you don’t know, or even realise that they exist. It’s a good job
nothing like that could happen in medicine.

Except, however,
research evidence can sometimes be as disquieting as a mirror in a brightly lit room. In
JAMA in 2006, Davis and colleagues did a systematic review comparing self-assessment with external observation. The evidence revealed that we are not very
good at assessing our own competence. Meanwhile, two years later In Medical
Teacher, another systematic review also shows us
that we are not that good at assessing our own learning needs.

In both situations it is the least skilled of
us who are the worst at self-assessing, and who are the most confident.

And then
there’s research that consistently shows we think we’re immune to drug repmarketing, no matter how often it’s shown that we’re not. This evidence is
entirely consistent with other sociological and psychological research, which
confirms that doctors are part of the human race, no matter how much we want to
think our training makes us otherwise.

Apply
Dunning and Kruger’s research to our profession, and you can see the danger in
asking “Are you a good doctor?” It may be the very areas in which we feel highly
confident are just those areas we are worst at. It may be that those of us
who think they are expert at seeing through drug rep spin are those most
susceptible.

What if those of us who say they are good doctors are the ones we
need to be most wary of?

Of course,
you could dispute the evidence. All that stuff about education and drug reps
doesn’t apply to you, or to Australia. But that is just what you would say,
wouldn’t you, if you were subject to the Dunning-Kruger effect!

In order to show how
competent we are, we might have to admit some uncertainty over our competence. In
fact, in real life, I have discovered that the doctors I really admire all feel
that they will be tapped on the shoulder and outed as a fraud at any moment.

For any
eager regulators out there wanting to put conditions on the registration of
anyone admitting they think they are a good doctor, the solution is even simpler. As a profession, with specific knowledge and expertise, self-regulation
often means peer review. We need - and should welcome - others around us to help
us see our blind spots. Perhaps “Are you a good doctor?” is not such a
dangerous question if the answer is “You’re asking the wrong person.”

References

Kruger J, Dunning D. Unskilled and unaware of it: how
difficulties in recognizing one's own incompetence lead to inflated
self-assessments. Journal of personality and social psychology. 1999
Dec;77(6):1121-1134.

This article first appeared in the July 2014 issue of the RACGP Publication Good Practice. It was written for a GP audience, who I hope would have fond memories of all the food terminology. Perhaps it was just me. The published version was edited slightly, but this is the original.

Being a
doctor makes me hungry. Surely, many of us spend a morning clinic thinking
about lunch, and an afternoon clinic wondering about dinner. I’m pretty sure it
has been the same throughout history. I imagine Hippocrates eating herring,
Galen tucking into grapes and Vesalius enjoying veal. However, I think they had
stronger stomachs than me. I trained at one of those traditional medical
schools that did dissection, and the combination smell of meat and formalin
meant I was never hungry.

This didn’t seem to be true for previous generations
of pathologists, though. All those historical types were clearly distracted by
their stomachs, as any quick leaf through a medical textbook will tell you. I
imagine that as their assiduous students examined yet more examples of
pathological body fluids, they’d ask their teachers for adequate descriptions.

“What does
this stool look like?”

“Redcurrant
jelly.”

“And this
one?”

“Rice
water. Better wash your hands. It’s supper time.”

There would
be no fluid too disgusting to describe in tasty terms, every internal organ was
ripe for culinary description.

“Your next
patient looks a little unwell. Yeuch, he’s just vomited in the waiting room.”

The
analogies continued. As they probed deeper, medicine became like a banquet. The
main course was cauliflower ear, with subtle flavouring found in livers that
looked like nutmeg. The cheese course was supplied by chest granulomas
described as caseating. No-one could resist the chocolate cysts on the ovaries.
After the food had settled, the skin was eagerly examined for port wine stains
and café-au-lait spots.

It appears
we might now be running out of foods to use. Arguments break out, amid
confusing errors as to precisely which diseased organ looks like a strawberry.

“Wasn’t it
that strawberry naevus?”

“No, I
thought it was a strawberry cervix.”

“Actually,
I was talking about the strawberry tongue. I’m not sure how you missed it!”

I’m not
sure I believe they really could see these things. Perhaps all they were
cooking were the books.

And back to
reality. If the thought of all that pathology puts me off my next meal, this is
reinforced by my next patients who bring with them the strangest of menus. The
first person tells me he has a frog in his throat. The next person has
butterflies in her stomach. She’s worried, she tells me. Something is eating
away at her. Up next is someone who knows something is wrong from her gut
instinct. It’s quite a relief to find my next patient is so hungry she could
eat a horse, but she is pleased as the treatment seems to be bearing fruit. My
final patient has a few lumps in various places, which I carefully examine and
document their sizes – a grain of rice, a pea, and, most surprisingly, a
grapefruit.

I reach the
end of my surgery, running particularly late. After this procession of
unpalatable symptoms, all I have the appetite for now is my apple, which is
successful at keeping the doctor away from his lunch.

As my
afternoon patients start arriving and peeling off their coats in the waiting
room, I anticipate the feast to come. I reassure myself that, running late,
slow food is healthier for all of us. Feeling better, my appetite for the work
is not diminished. I look forward to the afternoon with relish.